"KY RHB [Kentucky Radiation Health Branch] was notified on April 27, 2012, by the corporate RSO (CRSO) of Mistras Group, Inc. (license 201-699-05), that on the morning of April 27, 2012 he received a notice from Landauer that [an employee] received an extremely high dose reading on his film badge for the month of March 2012. The report stated that 'Dosimeter has exceeded the reporting capabilities of 1000 Rads, dosimeter reprocessed, second read agrees with reported dose.' The representative with Landauer told the CRSO that the image blinded the camera and was too blurry to read. She also stated that the reading was so high they could not get a reading. The CRSO conducted a telephone interview with [the employee] and he was told that his dosimeter never went off scale during that period and his film badge was on him at all times while performing radiography procedures. He did say his film badge may have been stored in his work bucket in the dark room of his transport vehicle. The CRSO has instructed [the employee] to turn in his [the employee's] current film badge to the office manager and is not to participate in radiographic operations until this matter has been resolved. According to a telephone conversation with the RSO early this evening, [the employee] is not experiencing any signs or symptoms of radiation exposure and he will be calling Oak Ridge tomorrow morning (5/1/12) to schedule blood work for [the employee]."

Kentucky Report: 120008

* * * THE RETRACTION FROM CURT PENDERGRASS TO JOHN SHOEMAKER AT 1538 EDT ON 7/17/12 * * *

The following retraction was received from the State of Kentucky via email.

The Kentucky Department of Radiation Control provided dose reconstruction results and corrective actions for EN 47879 purported overexposure of industrial radiographer. The Kentucky Department of Radiation Control wishes to retract this event due to the results in documents showing that, while this person's badge received a dose of 1,000 R, the individual received a dose of less than 200 mrem for the reporting period.

"During a review of environmental qualification records for reactor containment building electrical penetrations, six penetrations were identified that may not provide an adequate seal during worst case (Design Basis Accident (DBA)) conditions as required. These penetrations are through wall from the containment into the auxiliary building. The conditions that could cause degradation of the electrical penetration seals are not applicable to this operating mode. The station is currently in a refueling mode. This event was identified on March 2, 2012. The reportability was confirmed on May 1, 2012 at 1502 CDT."

The current penetration configuration has existed since the plant was built. The area of concern is that the Teflon connections may degrade under conditions of high radiation and high temperature during a DBA event. The licensee is investigating the extent of the condition and repair techniques.

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM ROBERT KROS TO PETE SNYDER AT 1523 ON 6/26/12 * * *

"On review of CR 2012-01947 by a new Project Manager, who was brought in as a subject matter expert on HELB/EEQ, and issue was identified with the 530 primary containment electrical penetration feed-throughs used for non-CQE devices. The CR [Condition Report] correctly notes that under the original accident testing, the Teflon seals failed, and water was noted leaking from these penetrations.

"On further review, the following was noted: Due to the design of the penetration feed-throughs, when the inboard Teflon seal fails (as it is expected to, due to high level of radioactivity in the primary containment, following a Loss of Coolant Accident (LOCA)), the atmosphere of the primary containment will be introduced to the penetration assembly, first through the failed seal or seals, and then through the weep hole between the inboard and outboard seals of the feed-through. This will put the same high level of radioactivity in direct contact with the outboard seals, resulting in the failure of its Teflon Seal. This would result in approximately 530 breaches of the Primary Containment during post LOCA conditions. The existing vendor analysis does not assume any contribution to the outboard seal exposure from the mixing of containment atmosphere with the penetration air after the failure of the inboard seal. This is probable, as each feed-through has a weep hole. Once the inboard seal fails, the penetration will be filled with containment atmosphere to equalize the pressure, which will bring the associated noble gas and Iodine fraction in proportion, into the penetration."

"During the extent of condition review for CR 2012-01655 and 2012-01947 additional penetration feed-through assemblies were identified that are subject to the same failure mechanism. These penetrations are associated with the containment sump recirculation isolation valves, and also associated with the personnel air lock."

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following information was provided by the State of California via facsimile:

"At 0818 [PDT] on July 9, 2012, RHB was notified by CalEMA [California Emergency Management Agency] that they had received a report of a stolen gauge. The gauge CPN MC-1DR #MD20706668) was discovered stolen this morning when the gauge user arrived at the job site in Ontario, CA. The lock on the mini storage trailer was broken and the chain that bolted the gauge (in the locked case) to the structure was broken and the gauge and case were removed. The gauge case was locked.

"At 1015 [PDT] on the same morning, the licensee reported the gauge and case had been found on a dirt road in another city from where it was stolen. There was no damage to the gauge and the lock had been removed from the case. The handle of the gauge was not locked and the licensee [was] cited because of this."

CA 5010 # 070912

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

The following information is provided by the State of Alabama via facsimile:

"On Thursday, June 28, 2012, representatives of Eastern Technologics, Inc. (ETI) notified the Alabama Office of Radiation Control of the discovery of a leak in the sewer drain that handles the waste water discharge from ETI's nuclear laundry facility in Ashford, Alabama. At that time, ETI was determining the extent of contamination caused by the leak. ETI is authorized to possess and use the radioactive material as part of their operations under Alabama Radioactive Material License No. 947. Under the conditions of this license, ETI is required to restrict effluent releases to sewers to ten percent of the maximum permissible concentrations specified in Appendix B, Table III of Agency [Alabama Office of Radiation Control] Rule 420-3-26-.03 for all radioisotopes (except Co-60). For Co-60, the licensee is required to restrict releases to 20 milliCuries each calendar year.

"ETI excavated the area and determined that the source of the leak was an elbow in the drain pipe. Access to the area identified as contaminated was restricted and controlled. Samples were taken by Alabama Office of Radiation Control personnel on July 1, 2012. The results of the analysis of those samples were made available on July 9, 2012 and identified contamination in the soil at levels greater than five times the lowest annual limit of intake (ALI) as specified in the Agency [Alabama Office of Radiation Control] rules.

"ETI is currently decontaminating the site by excavating the contaminated soil. Personnel from the Alabama Office of Radiation Control are monitoring activities and taking confirmatory samples to verify clean up standards. The cause of the incident and the corrective measures by the licensee are pending at this time. The information is accurate as of 0900 CDT, July 10, 2012."

"The RSO received a phone call from the physicist who explained she incorrectly connected the HDR unit during a patient treatment. She explained how she connected a transfer tube to the endobronch catheter, when she should have connected the endobronch catheter directly to the HDR unit. This would add about 1 meter of distance between the intended treatment site and the HDR unit source.

"It was determined that the source exited the HDR unit, but never made it to the patient. This was confirmed by a repeat test/reproduction with a dummy patient/setup in the exact format the patient treatment was performed. It was clear from observing this set up a mistaken addition of about 1 meter of transfer tube was added and that the source did not make it to the patient treatment site, or to the patient at all, and instead would be within the endobronch catheter potentially exposing a portion of patient skin (confirmed not to be in direct skin contact). We then placed a farmer chamber, a MOSfet and an Ion chamber in locations where we determined would be the highest possible patient skin dose measurements. We determined the highest potential skin dose to be 1.8cGy/1.8rem (significantly below the 50rem medical event definition) to the patient arm/shoulder area, however due to a folded blanket that was placed in that location it prevented direct skin contact.

"The hospital staff has changed policy as of today, to include a time out for the physicist to verbally voice the assurance to the in room nurse of proper connection to the HDR unit. They are planning an education process for their nursing staff so they may visually assist as a secondary visual confirmation. They are also reassessing additional support staff to be present during HDR treatment in a future meeting. The RSO believes the error happened due to human error, and a rushed procedure that occurred at the end of the day.

"The hospital staff is assessing the patient for potential skin burns both now and in the future (2wk, 5wks for reassessment). They do not expect to see skin burns, but will perform this patient skin burn assessment for assurance and to confirm our lower dose skin estimates. They intend on completing the patient treatment and therefore will complete this written directive dose which was scheduled for 500cGy, based upon the medical consult with the Radiation Oncologist. We are in process of follow-up with the patient, and referring physician."

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

The following information was obtained from the Commonwealth of Kentucky via email:

"A prostate seed implant was performed on June 4, 2012. The procedure presented with some complications related to a deficit from a TURP [Transurethral Resection of the Prostate] surgery performed on the patient over 15 years ago. When the procedure was completed cystoscopy identified no seeds in the bladder or urethra.

"The patient returned for the post implant CT on July 9, 2012. During the post implant visit with the Authorized User, the patient identified he had passed what was thought to be two seeds. Further discussion with the Authorized User identified it was two strands of seeds. The patient flushed one strand into his septic system and will bring the second strand back to the licensee for proper disposal.

"The post implant CT determined approximately 15 seeds were missing from the implant. It appears the two strands containing these seeds were in the deficit resulting from the earlier TURP surgery.

"The licensee is preparing a report for submission to the RHB within the next 15 days."

"On July 17 2012, at 1118 [EDT], Nine Mile Point Unit 1 experienced an automatic reactor scram due to high neutron flux as measured by the Average Power Range Monitoring system. The cause is currently under investigation. All control rods fully inserted and all plant systems responded per design following the scram. The High Pressure Coolant Injection [HPCI] system, which is an operating mode of the feedwater system, initiated as expected. There were no planned activities in progress at the time which could have contributed to the event.

"Nine Mile Point Unit 1 is currently in Hot Shutdown, with reactor water level and pressure maintained within normal bands. Decay heat is being removed via steam to the main condenser using the bypass valves. The offsite grid is stable with no grid restrictions or warnings in effect. All emergency power sources are available in standby.

"The unit is currently implementing post scram recovery procedures."

This was an uncomplicated Reactor Scram and the plant is stable with normal levels, temperature, and pressure. Offsite power is in a normal alignment. HPCI has been secured and returned to normal alignment. The cause to the high neutron flux is still under investigation. This event had no impact on Unit 2.

The licensee has informed the NRC Resident Inspector and State Authorities.

"Results of a thermal fatigue analysis on the Chemical and Volume Control System (CVCS) charging line concluded that the socket weld fittings above the RCS piping cannot be qualified.

"As an interim action, shut down cooling purification has been secured and charging has been isolated to the RCS.

"The plant is shutdown and in Mode 5 with the reactor vessel head removed, so RCS is not intact and not required to be for current plant conditions. This report is being made in accordance with 10CFR50.72(b)(3)(ii)(A) for a degraded condition."

TECHNICAL SUPPORT CENTER NON-FUNCTIONAL DUE TO DEGRADED CHARCOAL ADSORBER

"At 1140 [EDT] on Tuesday, July 17, the Callaway Plant Technical Support Center (TSC) was declared non-functional due to a degraded charcoal filter in the building's filter absorber unit. At 1140 [EDT] on July 17, 2012, Callaway was notified of the test results for a charcoal test sample that was taken on July 5, 2012. The results did not meet surveillance procedure acceptance criteria.

"Efforts are underway to replace the charcoal in the unit.

"If an emergency were to be declared requiring activation of the TSC while it is non-functional, TSC emergency response personnel would report to their backup locations in accordance with Callaway Plant emergency planning procedures.

"This notification is being made in accordance with 10 CPR 50.72(b)(3)(xiii) due to the unavailability of an emergency response facility.

"This 60-day telephone notification is being made per the reporting requirements specified in 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(3)(1) to describe an invalid actuation signal affecting containment isolation valves in more than one system.

"On May 24, 2012, Nine Mile Point Unit 2 (NMP2) received a Division 2 primary containment isolation signal which resulted in closure of Group 3, 8, and 9 primary containment isolation valves (PCIVs) in the following systems:

"All affected PCIVs responded as designed. In addition, the Division 2 containment isolation signal resulted in isolation of the Reactor Building normal ventilation system, starting of the Division 1 and Division 2 standby gas treatment subsystems, starting of the Division 1 and Division 2 Reactor Building safety-related unit coolers, and starting of the Division 2 Control Room envelope filtration subsystem.

"The Division 2 isolation signal was generated during a maintenance activity involving the replacement of a relay in a main control room panel. During the activity, an installed jumper became dislodged from its point of origin, leading to a blown control power fuse and generation of the Division 2 isolation signal. Since the isolation signal was not initiated in response to actual plant conditions or parameters satisfying the requirements for initiation, the isolation signal was determined to be invalid.

"This event was entered into the corrective action program as Condition Report (CR) 2012-005128. There were no safety consequences or impact on the health and safety of the public as a result of this event."

"On July 17, 2012, at 1120 hours the Control Room Emergency Ventilation Air Conditioning (CREV AC) system was declared inoperable due to a cooling water leak from the condenser on the Refrigeration Compressor Unit (RCU). The leakage originates from an apparent gasket leak at a bolted connection on the condenser. As a result, Technical Specification 3.7.5, Condition A, was entered. A repair plan and schedule is being developed.

"The CREV AC system maintains a habitable control room environment and ensures the operability of components in the control room emergency zone during accident conditions.

"This notification is being made in accordance with 10 CFR 50.72(b)(3)(v)(D) because the CREV system is a single train system, and loss of the CREV AC could impact the plant's ability to mitigate the consequences of an accident."

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO SMALL RCS PRESSURE BOUNDARY INSTRUMENT LINE LEAK

"At 1715 EDT on July 17th, 2012, Calvert Cliffs Nuclear Power Plant Unit 1 identified RCS Pressure Boundary Leakage from the instrument line to 1-PDT-123A, 11A reactor coolant pump differential pressure transmitter. Technical Specification 3.4.13, Action B was entered and requires that the Unit be placed in Mode 3 within 6 hours and Mode 5 within 36 hours. The licensee has initiated plant shutdown in accordance with this Technical Specification. Therefore, this is reportable under 10 CFR 50.72(b)(2)(i) Plant Shutdown Required by Technical Specifications. This is also reportable under 50.72(B)(3)(ii)(A) as a material defect in the primary coolant system that cannot be found acceptable under ASME Section XI, IWB-3600 or ASME Section XI, Table IWB-3410-1."

The licensee initially discovered the leak during an RCS leak rate surveillance that indicated RCS leakage on the order of 0.08 gpm. A video camera was used to look for the leak and was found to be on the identified instrument line. The licensee has initiated a power reduction and is currently at approximately 50%.

The recovery plan at this time is to reduce power to about 10% which will reduce radiation levels in the area of the leak and isolate the instrument line and isolate the leakage. The instrument line is for a reactor coolant pump differential pressure transmitter which is for monitoring purposes only and does not provide any safety related functions. If the leak can be secured, the licensee intends to return to power. If the leak cannot be secured, the plant will shutdown in compliance with the technical specification action statement.